Harking back to a disco classic, I have to put my hands up and admit that I’ve reached the end of my tether with Fiasp after nine months, even after mixing it, both in an F50N (50% Fiasp/Novorapid) and an F40N (40% Fiasp, 60% Novorapid) formulation.
The angry red pump sites came back and the inability to lower blood glucose levels also returned. So instead I returned to my old buddy Novorapid.
And almost instantly it proved to make the difference I had observed when using it in September. I’d like to call it “Old Reliable” as, with appropriate “Eating Soon” and pre-bolusing, those annoying post-prandial climbs that just wouldn’t reduce seem to have gone away.
As an aside, what I’ve also found is that if I carry a small syringe of Fiasp, I can use that effectively via injection to counter a postprandial rise when eating something that is perhaps higher in fast carbs and unplanned compared with the necessary preparation for Novorapid.
Whilst I know that not all Fiasp users have been affected, it feels like a significant minority.
Discussing these effects in various groups on Social Media, there’ve been a fair number of people express similar issues. So it’s interesting to see that someone has finally published an additional paper on the use of Fiasp in pumps, to enhance the limited information available from the EMA submission.
In an article entitled “Pump Users Clamor for Faster Insulin: Is Fast-Acting Insulin Aspart Ready for Them?“, there is discussion of the small scale study undertaken by Zijlstra for the EMA approval that has results that raise similar questions to those raised in social media.
As I and others have mentioned, there was limited Pump Compatibility testing in the EMA submission and this article goes into further details of what was published within that.
What the results highlight, however, is that there are other issues arising.
To cut a long story short, this was a small study with 37 participants randomized 2:1 Fiasp:Novorapid and lasted only six weeks, with a primary endpoint of the number of microscopically confirmed infusion set occlusions during the 6 weeks of treatment. This turned out to be zero in all cases. What makes this odder is that seven expected occlusion events were reported, all for Fiasp, none of which were proved to be occlusion related.
Another endpoint was frequency of premature set changes, and once again, there were a total of 21 premature set changes in 44% of the Fiasp users, compared to a total of four in 17% of Novorapid users. Taking this a step further, one third of those in the Fiasp users group could be attributed to technical issues, where as three quarters in the Novorapid users had the same origin.
So if we weight for number of users in each part of the study, we can see that:
- The Fiasp group experienced 700% of the premature set changes that Novorapid users saw. There were two premature set changes per 25 users in the Novorapid group versus 14 per 25 in the Fiasp group, none of which could be explained on a technical or occlusion basis
- 40% of Fiasp users suffered unexplained hyperglycaemia as opposed to 25% of the Novorapid users. Of those, six were unexplained, and seven were thought to be occlusion related, which was later disproved.
For me though, the telling aspect of this is the following statement from the conclusions drawn (the emboldened text done for emphasis):
Pump users should be advised that FIASP may result in the need for additional premature infusion set changes and that more episodes of unexplained hyperglycemia may be expected and should be scrupulously evaluated.
As in everything else in life, risks and benefits need to be balanced, and the likely treatment benefits of FIASP should be weighed against these potential downsides for pump users. When definitive large-scale pump study results are available then these recommendations can be revisited.
Nowhere in the package insert do these points get mentioned, and while the EMA released Fiasp with “Enhanced Observation”, there was no mention of what needed to be observed.
This raises an interesting question. If you know, as the manufacturer, that a product you are about to release has characteristics that are potentially unusual, or may be counter to what the product is supposed to do, do you have a duty of care to publish this information? If you don’t publish it, how do users and healthcare professionals know that there was a recommendation to scrupulously evaluate issues?
Would I have changed my decision to use Fiasp if I’d known this? No. Would it have been better to understand that there have been unexplained hyperglycaemic events during testing and further investigation of them was needed? Yes.
As has been discussed in a number of other places, it looks a little as though the use of Fiasp in pumps is much more a Beta release than with MDI. It was a Beta that I happily participated in, but as with any Beta, easy access to the release notes and questions as to what to look out for, plus an easy, direct route for feedback is preferable.
What remains to be seen is what longer term effects are observed in longer, larger pump studies. Will they back up those seen in the vanguard of users or will we get a different story? Whichever it is, I don’t want to see pharma companies stop producing new products or releasing them to us as vanguard users. We want to try them out and want to give our feedback. Just please be more open about what the real risks may be!
Footnote: If you’re a Fiasp user, and especially if you’ve seen similar, I’m trying to collect together user experiences so that they can be shared with those who are interested. You can find the submission form here. The responses so far can be found by following this link.